Electrophysiological subtypes and associated prognosis factors of Mexican adults diagnosed with Guillain-Barré syndrome, a single center experience

Effect of intravenous immunoglobulin and plasmapheresis on nerve conduction parameters compared to the natural course of Guillain-Barré syndrome

BACKGROUND

Intravenous immunoglobulin (IVIg) and plasmapheresis (PLEX) are recommended in moderate to severe Guillain-Barré Syndrome (GBS), but there is paucity of studies evaluating its effect on nerve conduction studies (NCS). We report the effect of IVIg and PLEX on the NCS parameters and clinical outcomes compared to natural course (NC) of GBS patients.

METHOD

Moderate to severe GBS patients were included based on clinical, cerebrospinal fluid, and NCS finding. Six motor and sensory nerves were evaluated at admission, one month and 3 months, and NCS subtyping was done. Axonal and demyelination burden in motor nerves and early reversible conduction block (ERCB) were noted. Patients receiving IVIg, PLEX or on NC were noted. Outcome was defined at 3 months into complete, partial and poor using a 0-6 GBS Disability Scale (GBSDS).

RESULT

Seventy-two patients were included, whose median age was 36 years and 22(30.6 %) were females. 44 patients received IVIg, 9 PLEX and 19 were in NC, and they had comparable peak disability. AIDP was the dominant subtype at admission (58.3 %), which remained so at 3 months (50 %). The shift of subtypes was the highest from the equivocal group followed by AMAN and the least from AIDP. IVIg and PLEX group had more reduction in axonal burden and had ERCB compared to NC. 33(44 %) patients had complete recovery, and 40(55.5 %) patients had concordance in clinical and neurophysiological outcome.

CONCLUSION

Transition of GBS subtype may occur at follow-up from all the subtypes, the highest from the equivocal and the lowest from the AIDP group. IVIg/PLEX treatment may help in reducing conduction block and axonal burden.

Factors Predicting Prolonged Mechanical Ventilation in Guillain-Barré Syndrome

BACKGROUND

Up to 30% of patients with Guillain-Barré syndrome require mechanical ventilation and 5% die due to acute complications of mechanical ventilation. There is a considerable group of patients that will need prolonged mechanical ventilation (considered as >14 days) and should be considered for early tracheostomy. The objective of this study is to identify risk factors for prolonged mechanical ventilation.

METHODS

We prospectively analyzed patients with Guillain-Barré diagnosis with versus without prolonged mechanical ventilation. We considered clinical and electrophysiological characteristics and analyzed factors associated with prolonged mechanical ventilation.

RESULTS

Three hundred and three patients were included; 29% required mechanical ventilation. When comparing the groups, patients with prolonged invasive mechanical ventilation (IMV) have a lower score on the Medical Research Council score (19.5 ± 16.2 vs 27.4 ± 17.5, p = 0.03) and a higher frequency of dysautonomia (42.3% vs 19.4%, p = 0.037), as well as lower amplitudes of the distal compound muscle action potential (CMAP) of the median nerve [0.37 (RIQ 0.07-2.25) vs. 3.9 (RIQ1.2-6.4), p = <0.001] and ulnar nerve [0.37 (RIQ0.0-3.72) vs 1.5 (RIQ0.3-6.6), p = <0.001], and higher frequency of severe axonal damage in these nerves (distal CMAP ≤ 1.0 mV). Through binary logistic regression, severe axonal degeneration of the median nerve is an independent risk factor for prolonged IMV OR 4.9 (95%CI 1.1-21.5) p = 0.03, AUC of 0.774, (95%CI 0.66-0.88), p = < 0.001.

CONCLUSIONS

Severe median nerve damage is an independent risk factor for prolonged mechanical ventilation.

Practice of gait training using lower-limb orthosis and body weight-supported walker for severe acute motor axonal neuropathy: a case report

Kikkawa T, Takashima A. Practice of gait training using lower-limb orthosis and body weight-supported walker for severe acute motor axonal neuropathy: a case report. Jpn J Compr Rehabil Sci 2023; 14: 49-53.

Introduction

Acute motor axonal neuropathy (AMAN) requires aggressive gait rehabilitation from the early phase of its onset due to the long time required to achieve independent gait. In this report, we describe the progress of gait training using a combination of lower-limb orthosis and body weight-supported (BWS) walker in a patient with severe AMAN.

Case

A 30-year-olds man diagnosed with AMAN underwent two high-dose intravenous immunoglobulin treatments and combined steroid pulse therapy. The patient was admitted to the convalescent rehabilitation ward for 87 days with a Medical Research Council (MRC) score of 7 points for muscle strength and 13 points for Functional Independence Measure (FIM) motor items. He started gait training with a knee-ankle-foot orthosis on the 128th day. Thereafter, the distance of gait training increased with the use of lower-limb orthosis and BWS walker. At the time of discharge, the patient's MRC score had improved to 24 points and his FIM motor items score to 31 points. He was able to walk 90 m using ankle-foot orthosis and forearm walker and was transferred to a rehabilitation facility on day 237.

Discussion

Gait training with lower-limb orthosis and BWS walker was performed on a patient with severe AMAN. As a result, gait training distance increased without adverse events. Gait training can be performed safely and effectively by combining lower-limb orthosis and BWS walker when gait ability is expected to improve, even in severely ill patients.

Sural nerve involvement in Guillain-Barré syndrome: Clinical and prognostic implications. A prospective cohort

BACKGROUND

Sural sparing is common in Guillain-Barré syndrome (GBS). However, one third of patients have sural nerve compromise. Its clinical implications associated factors and short-term prognosis are still unknown. The objective of this study is to identify if sural nerve compromise is associated with a worse prognosis and to describe clinical and electrophysiological characteristics in Guillain-Barré syndrome.

MATERIALS AND METHODS

We prospectively analyzed patients with Guillain-Barré diagnosis with vs without sural nerve compromise. All patients underwent nerve conduction studies within the first 3 days of hospital admission. Clinical and electrophysiological characteristics were compared between groups.

RESULTS

174 patients were included in this study. Acute inflammatory demyelinating polyneuropathy was the predominant variant (43.7 %). Thirty percent of patients had sural nerve involvement. In the comparative analysis between affected vs unaffected sural groups, age ≥50 years and Guillain-Barré disability score ≥3 demonstrated a statistically significant difference. Regarding short-term recovery period for independent walking, there was no significant difference. In the multivariate analysis, age ≥50 years was identified as independent factors for sural nerve compromise on admission.

CONCLUSION

sural nerve compromise occurs in 30 % of patients with GBS and is not associated with a worse functional prognosis. Age ≥50 years was identified as an independent factor for sural nerve compromise.

Predictors of Mechanical Ventilation in Guillain-Barré Syndrome with Axonal Subtypes

BACKGROUND

The early clinical predictors of respiratory failure in Latin Americans with Guillain-Barré syndrome (GBS) have scarcely been studied. This is of particular importance since Latin America has a high frequency of axonal GBS variants that may imply a worse prognosis.

METHODS

We studied 86 Mexican patients with GBS admitted to the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, a referral center of Mexico City, to describe predictors of invasive mechanical ventilation (IMV).

RESULTS

The median age was 40 years (interquartile range: 26-53.5), with 60.5% men (male-to-female ratio: 1.53). Most patients (65%) had an infectious antecedent (40.6% gastrointestinal). At admission, 38% of patients had a Medical Research Council (MRC) sum score <30. Axonal subtypes predominated (60.5%), with acute motor axonal neuropathy being the most prevalent (34.9%), followed by acute inflammatory demyelinating polyneuropathy (32.6%), acute motor sensory axonal neuropathy (AMSAN) (25.6%), and Fisher syndrome (7%). Notably, 15.1% had onset in upper limbs, 75.6% dysautonomia, and 73.3% pain. In all, 86% received either IVIg (9.3%) or plasma exchange (74.4%). IMV was required in 39.5% patients (72.7% in AMSAN). A multivariate model without including published prognostic scores yielded the time since onset to admission <15 days, axonal variants, MRC sum score <30, and bulbar weakness as independent predictors of IMV. The model including grading scales yielded lower limbs onset, Erasmus GBS respiratory insufficiency score (EGRIS) >4, and dysautonomia as predictors.

CONCLUSION

These results suggest that EGRIS is a good prognosticator of IMV in GBS patients with a predominance of axonal electrophysiological subtypes, but other early clinical data should also be considered.

Reversible conduction failure in acute inflammatory demyelinating polyneuropathy

Reversible conduction failure (RCF) has been documented in acute motor axonal neuropathy (AMAN) and is considered a sign of nodopathy. Several reports of RCF in acute inflammatory demyelinating polyneuropathy (AIDP) have suggested that it could be a manifestation of nodopathy. We conducted this study to determine the frequency of RCF in AMAN and AIDP and to compare the clinical features between the two groups with or without RCF. RCF was observed in 38.9% and 18.5% patients in the AMAN and AIDP groups in our study, respectively. AIDP patients with anti-ganglioside antibodies represented 29.4% of the cohort. The clinical features of AIDP with RCF were more similar to those of AMAN with RCF than to those of typical AIDP. However, there were no significant differences in the frequency of anti-ganglioside antibody status between the groups. AIDP with RCF may be a manifestation of nodopathy. The current dichotomous electrodiagnostic criteria, classifying demyelinating and axonal neuropathy, are insufficient to define nodopathy. Further studies are required to revise the electrodiagnostic criteria for Guillain-Barré syndrome.

Incidence of Guillain-Barré syndrome following SARS-CoV-2 immunization: Analysis of a nationwide registry of recipients of 81 million doses of seven vaccines

Background and purpose

Information on Guillain–Barré syndrome (GBS) as an adverse event following immunization (AEFI) against SARS‐CoV‐2 remains scarce. We aimed to report GBS incidence as an AEFI among adult (≥18 years) recipients of 81,842,426 doses of seven anti‐SARS‐CoV‐2 vaccines between December 24, 2020, and October 29, 2021, in Mexico.

Methods

Cases were retrospectively collected through passive epidemiological surveillance. The overall observed incidence was calculated according to the total number of administered doses. Vaccines were analyzed individually and by vector as mRNA‐based (mRNA‐1273 and BNT162b2), adenovirus‐vectored (ChAdOx1 nCov‐19, rAd26‐rAd5, Ad5‐nCoV, and Ad26.COV2‐S), and inactivated whole‐virion‐vectored (CoronaVac) vaccines.

Results

We identified 97 patients (52 males [53.6%]; median [interquartile range] age 44 [33–60] years), for an overall observed incidence of 1.19/1,000,000 doses (95% confidence interval [CI] 0.97–1.45), with incidence higher among Ad26.COV2‐S (3.86/1,000,000 doses, 95% CI 1.50–9.93) and BNT162b2 recipients (1.92/1,00,000 doses, 95% CI 1.36–2.71). The interval (interquartile range) from vaccination to GBS symptom onset was 10 (3–17) days. Preceding diarrhea was reported in 21 patients (21.6%) and mild COVID‐19 in four more (4.1%). Only 18 patients were tested for Campylobacter jejuni (positive in 16 [88.9%]). Electrophysiological examinations were performed in 76 patients (78.4%; axonal in 46 [60.5%] and demyelinating in 25 [32.8%]); variants were similar across the platforms. On admission, 91.8% had a GBS disability score ≥3. Seventy‐five patients (77.3%) received intravenous immunoglobulin, received seven plasma exchange (7.2%), and 15 (15.5%) were treated conservatively. Ten patients (10.3%) died, and 79.1% of survivors were unable to walk independently.

Conclusions

Guillain–Barré syndrome was an extremely infrequent AEFI against SARS‐CoV‐2. The protection provided by these vaccines outweighs the risk of developing GBS.

Guillain-Barré syndrome following SARS-CoV-2 vaccination: Is there a real association?

Background

Guillain-Barre Syndrome (GBS) is the most common cause of acute flaccid paralysis, with an incidence of 0.81–1.89 cases per 100,000. With the SARS-CoV-2 virus pandemic, major international vaccination campaigns continue to be carried out to minimize the total burden of the disease. This study aims to report a case series of consecutive GBS patients after SARS-CoV-2 vaccination during the massive campaign in Mexico in 2021.

Methods

A single-center, observational study of consecutive GBS subjects diagnosed by Asbury criteria from January 1 to August 31, 2021. Including GBS-related symptoms on or after six weeks of vaccination record, both first and second doses.

Results

From a total of 53 GBS patients, eight had a history of SARS-CoV-2 vaccination, 87.5% male, the median vaccination-symptom onset and symptom-to-admission time were 15 (IQR 12.75–23.25), and 3.5 (IQR 1.5–8.25), all of them had GBS Disability Scale ≥3 at admission. Acute inflammatory demyelinating polyneuropathy (AIDP) was the most common electrophysiological variant encountered in this population. All patients received treatment Intravenous Immunoglobulin (IVIG) or Plasma Exchange (PE), 62.5% recovered independent walk at three months follow up.

Conclusion

The annual incidence of GBS cases associated with vaccination remains lower (0.81 - 1.89 cases / 100,000 persons) than non-vaccinated patients; this should encourage health authorities to continue promoting massive vaccination as benefits outweigh the risks.

Prognostic Factors in Elderly Patients With Guillain-Barré Syndrome: Does Age Matter?

Introduction

Twenty to 40% of Guillain Barré syndrome (GBS) patients will not be able to walk independently despite effective treatment. Older patients carry additional risks for worse outcomes.

Methods

A single center, ambispective cohort study was performed. Only subjects ≥18 years with a 3-month follow-up were included. Elderly patients were considered as a whole if ≥ 60 years. Demographics, CSF and nerve conduction studies were compared. A binomial logistic regression and Kaplan-Meier analyses were carried out to estimate good prognosis (Hugues ≤2) at 3-month follow-up.

Results

From 130 patients recruited, 27.6% were elderly adults. They had a more severe disease, higher mEGOS and more cranial nerve involvement. Age ≥70 years, invasive mechanical ventilation and axonal subtype, portrayed an unfavorable 3-month outcome. Further analysis demonstrated an earlier recovery in independent walk at 3 months for patients <70 years.

Conclusions

Elderly patients with GBS have a more severe disease at admission and encounter worse prognosis at 3-month follow-up, especially those above 70 years.